Therapy At Your Fingertips

The following questions will help determine what issues you want to work on as well as determining if internet therapy would be useful for your specific needs. The questions are divided into three areas- demographic information, previous and current treatment, and issues with which you want help.

Last Name:
First Name:
Middle Intitial:
E-Mail

Birthday

Address
Street Name

State
Zip Code

Contact Phone Number
City

Have you ever had therapy before?	Yes No
If so, when was the last session?
Are you currently in therapy?	Yes No
Why are you choosing online therapy?

How are you feeling today?
How long have you been feeling this way?
What issues would you like to work on in therapy?
Have you been feeling sad, down or depressed?	Yes No
Have you lost interest in doing things you normally enjoy?	Yes No
Have you had times when you experienced several days of feeling elated or unusually irritable or argumentative, and you normally don’t feel this way?
Do you consider yourself to be a worrier, a nervous person, or very tense?	Yes No
Have you ever had a panic/anxiety attack in which you became extremely fearful or anxious?	Yes No
Do you have a lot of anxiety in social situations?	Yes No
Do you have specific fears or phobias?
Have you ever had trouble doing the same thing over and over again and can’t stop when you try?	Yes No
Do you feel like drinking alcohol or using drugs has been a problem for you or your family?	Yes No
Have you ever been in a traumatic situation in which your life was in danger?	Yes No
Have you ever binged on food or has anyone ever told you that you were too thin or losing too much weight?	Yes No
Do you ever hear or see things that other people don’t hear or see?	Yes No
Do you ever think someone is out to get you?	Yes No
Are you easily distracted or do you have a difficult time concentrating or staying focused?
Have there been any major changes or stressors in your life recently?	Yes No
If so, explain.

If you are feeling suicidal, seek help immediately by contacting an emergency number in your area (like 911), or going to any Emergency Room to be evaluated, or contacting a crisis line. Two crisis lines that can be accessed are 1-800-suicide or 1-800-273-talk.

home | sessions | prices | faq